Provider Demographics
NPI:1467992164
Name:PETERSON, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8500
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:CO
Mailing Address - Zip Code:81226-8500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5880 STATE HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:CO
Practice Address - Zip Code:81226-9791
Practice Address - Country:US
Practice Address - Phone:719-784-9464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5008103TC0700X
TX36674103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical